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01A,-,v ro y ss7sc 061'D 277 /7/:_3 <br /> commerce.Wi.gov OCT 6 100,0T afety and Buildings Division County <br /> Washington Ave.,P.O.Box 7162 DCivie. <br /> tiscontin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 5/S 1 8 3 <br /> Sanitary-Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental PAA( . p-.7ty (1 <3 7,r 7 <br /> y <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information t11i vi.' tt T <br /> Property Owner's Name Parcel# <br /> LA-v., 4. S kna lAAtistote n '`• SD le:i -D\itt cpiwt xi t_--o - 3- 3---7=•37- , <br /> Property Owner's Mailing Address Property Location <br /> el jS t YvtestYht KT C-1- Govt.Lot <br /> City,State Zip Code Phone Number 1V\Ai y 1\!w Y, Section `,) <br /> 3 5' (circle one) <br /> UC'Y one, t Lv( T f? N; R 3 E of-W <br /> II.Type of Building(check all that apply) . # <br /> L�1 or 2 Family Dwelling-Number of Bedrooms 7 Subdivision Name <br /> -OW Brock-#, 15c4 ,vv-r, -kit vt <br /> D Public/Commercial-Describe Use D City of <br /> CSM Number D Village of <br /> D State Owned-Describe Use <br /> g Town of (-->n1 YJ{-,C(A <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> , A. L7 Ncw System D Replacement System D Treatment/Holding Tank Replacement Only D Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> B. D Permit Renewal D Permit Revision D Change of Plumber D Permit Transfer to New <br /> Before Expiration Owner <br /> IV. type of POWTS System/Component/Device: (Check all that apply) • <br /> 0/Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> D Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> i <br /> I I 1575 1D-4Or. I,.)1.� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units P t j <br /> W V V t; N <br /> New Tanks Existing Tanks , e o u J- o n <br /> ° w O o. <br /> aU rn h <br /> Septic orli rldwg Tank 1.�Sd7 — 1 i->!5 r7 i I`-KALIL X <br /> Dosing Chamber ---,O e) I , A <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's SignaturePP/MPRS Number Business Phone Number <br /> ,1 , - Z1z?�<:-� B J 1 103 <br /> fly-eitz-�ry IN . NY-';P,EAc.Z --'f�- sL__— Lc.�, � j <br /> Plumber's Address(Street,City,State,Zip Code) 4✓ <br /> S C-fl-4 K tr'i%n a IAA K•e e , V-l 5S --3-7 • <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issmn Age-ntt ignatur" <br /> Approved ❑Disapproved g e1, (B r7-( Q l�f �/"l <br /> , C ,'k/l-S- <br /> D Owner Given Reason for Denial / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ---- .5. -6- roc;✓1f i'1r /'v(EA-1�w 7 // .4 N <br /> A <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 112 a 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />